Site Address ______________________________________

Owner Name _____________________________________

Address__________________________________________

Phone __________________

* Brief Description of Proposed Activity / Structure:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

* Be sure to attach any related drawing, site plan, work order, contract.

* * * * * * * * * * * * * * Office Use * * * * * * * * * * * * * * *

Appl Date ____ Fee Paid ______ Check # _____ Received By ______

Zoning District ____ Approval Date ______ Approved By ________